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General NPI Number Information
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NPI Number | 1316436439
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Entity Type | Individual
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Provider Name | MARDREY ALICIA WADE KILES LPC
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Gender | Female
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Dates
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Enumeration Date | 05/03/2018
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Last Update Date | 08/26/2024
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Provider Practice Location Address
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Address Line | 5104 STAGE RD
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City | MEMPHIS
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State | TN
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Zip | 38134-3164
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Country | US
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Telephone | 901-646-1053
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Fax | 901-424-9078
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Provider Business Mailing Address
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Address Line | 1788 CHESHUNT LN
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City | CORDOVA
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State | TN
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Zip | 38016-3507
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Country | US
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Telephone | 901-870-8682
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Fax | 901-424-9078
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4255
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License Number State | TN
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